‘Step Up’ Program Seeks to Reduce Them

By Annette M. Boyle

TAMPA, FL—Diabetic foot ulcers (DFU) have long been known to increase the risk of infection and amputation. They also elevate the risk of falls and fractures, according to recent research.

Foot ulcers affect about 25% of diabetics and lead to more hospital admissions than any other complication of the disease, a large study in Diabetes Care found. Veterans developed 165,187 new diabetic foot ulcers last year, an increase from 97,836 in 2015, according to the VA Prevention of Amputation in Veterans Everywhere (PAVE) data. 1

Health science specialist Tova Bergsten of the VA New York Harbor Healthcare System watches as Army Reserve Vietnam-Era veteran Stephen Fisher uses a special thermometer to help detect early-stage ulcers in his feet. Photo by Claudie Benjamin)

Researchers at the James A. Haley Veterans’ Hospital in Tampa, FL, recently discovered that diabetic patients with diabetic foot ulcers have more than twice the risk of falling and more than three times the risk of fractures compared to diabetics who do not have DFUs. The results of their study were published in Ostomy Wound Management.2

“Patients with diabetes commonly experience falls and fractures which may be associated with insensate feet and comorbidities. Falls and fractures may lead to traumatic injury that can contribute to or increase the risk of diabetic foot ulcer development,” said lead author Latricia Allen, DPM, MPH, of the Tampa VAMC.  In addition to perpetuating a cycle of diabetic foot ulcers and injuries, falls and fractures can lead to serious complications such as brain injury, loss of independence, loss of mobility, institutionalization and death in older patients.

The Tampa researchers reviewed the records of all diabetic patients treated at their hospital between 2009 and 2014. Of those, 41,324 had diabetes without a foot ulcer and 3,238 had both diabetes and DFU. The population was predominately male (96%) and white (78%).

The two most common comorbidities were peripheral neuropathy, which affected 23.2% of the patients with DFU and 6.1% of those without ulcers, and peripheral vascular disease, present in 39.5% of those with foot ulcers and 9.2% of those without DFU. Peripheral neuropathy can lead to gait issues that may increase the risk of falls, while peripheral vascular disease can delay healing and increase the risk of infection in ulcers, the authors noted. Both conditions can also reduce a patient’s ability to feel pain, allowing an ulcer to develop undetected.

The study confirmed a known association between DFU and both infection and amputations. Patients with diabetes and foot ulcers had more than nine times the risk of infection and more than seven times the risk of amputation. “Infection and amputation were expected AEs in the diabetes with DFU patient population due to the nature of the disease,” the authors wrote. “The increased risk of falls in persons with diabetes and DFU has not been well noted in the literature and needs to be examined further.”

Appropriate Resources

The study highlights the need to reduce the risk of diabetic foot ulcers and to improve fall risk screening, assessment and interventions in patients with DFU. “Important steps to reducing the risk of DFU are ensuring patients are screened to identify risk factors, educated regarding self-care, and promptly treated by specialists with appropriate resources such as evidence-based advanced wound care therapies to enhance wound healing and prevent amputation,” Allen told U.S. Medicine.

According to the American Podiatric Medical Association, Native Americans, African-Americans, Hispanics and older men with diabetes have a higher risk of developing foot ulcers. Neuropathy, poor circulation, foot deformities such as bunions or hammer toes, and habitually wearing ill-fitting shoes make foot ulcers more likely. Other risk factors include insulin use, smoking, alcohol consumption, hypercholesterolemia and uncontrolled glycemic levels.

Meanwhile, a group of VA researchers is trying to minimize the recurrence of diabetic foot ulcers. The VA Rehabilitation Research and Development Service awarded $1.1 million to the VA New York Harbor Healthcare System to prevent DFU.

The program, “STEP UP to Avert Amputation in Diabetes,” educates diabetic patients who have previously had a DFU about the risks associated with foot ulcers and trains them in self-care, including regularly checking their feet and wearing appropriate shoes. It also shows them how to monitor the temperature of the soles of their feet with a special thermometer. Inflammation leads to elevated readings, which may indicate that an ulcer is about to form.

Patients in the program who detect a higher than normal reading on just one foot are encouraged to rest and elevate the “hot” foot for 24 hours. If the temperature remains high, the patient follows up with a foot specialist, who will often recommend cushions or special shoes that protect the at-risk region of the foot.

Preventing recurrent foot ulcers will reduce the risk of amputation. More than 80% of the non-traumatic amputations in the VA are caused by complications of DFU, according to lead researcher Sundar Natarajan, MD, MSc. He said he hopes that the STEP UP program will “lead to a new strategy to prevent the devastating complications of foot ulcers.”

  1. Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons NB. Burden of diabetic foot ulcers for Medicare and private insurers. Diabetes Care. 2014;37(3):651-8. doi: 10.2337/dc13-2176. Epub 2013 Nov 1. Erratum in: Diabetes Care. 2014 Sep;37(9):2660.
  2. Allen L, Powell-Cope G, Mbah A, Bulat T, Njoh E. A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers. Ostomy Wound Manage. 2017 Jun;63(6):30-33.